When the terminally ill want to end their lives

PRACTICE DILEMMA - What do you do if a patient asks for help to die? 

THE DILEMMA

One of my patients is a 76-year-old man with myelofibrosis. He has had the condition for 12 years, and it is getting progressively worse.

He has to have frequent blood transfusions, and prior to the last one his haemoglobin was only 2.8g/dl. He told me that he had put off asking for help because he hoped that he might die, but the attendant breathlessness was so distressing that he had to give in and request a transfusion.

To make matters worse, last year he was diagnosed with carcinoma of the prostate with bony secondaries, so his outlook is poor on two counts and his quality of life is degrading rapidly.

When I went to see him after his last admission, he pleaded with me to give him information about euthanasia, and in particular he wanted me to introduce him to the organisation in Switzerland that recently received so much publicity. He has found he cannot die peacefully by refusing treatment because of the agonising breathlessness. How far can I go to help him achieve his aim?

A GP'S VIEW

Dr Lorna Gold, a GP locum in Glasgow

This patient is telling me that he has accepted he is going to die soon, that he wants a swift and dignified death, and is not confident that this perfectly reasonable and achievable desire will be fulfilled by his current treatment.

His desire for active euthanasia is by no means irrational, but I suspect he is aware that it is something I cannot offer him.

I would acknowledge his question, and explain that even if I could refer him to an organisation in a country in which euthanasia is legal, he would be unable to make the journey because no airline would accept him and any other form of travel would be intolerably distressing for him.

I shall also explain that I will do everything possible to ease his passing, and pain and breathlessness are among the more easily manageable symptoms of advanced cancer.

I would ask him to let me review his medication and his care arrangements in conjunction with the local palliative care team, and suggest that he consider admission to a hospice, especially if he lives alone. This will allow his medication to be adjusted promptly as his breathlessness increases, and may give him a more peaceful death.

A PATIENT'S VIEW

Ian Semmons, chairman, National Patient's Network

This elderly man has come to you at his lowest ebb, no doubt worn out by the continuing debilitating impact of his condition. To many, this may appear a perfectly reasonable request as it is hard to imagine anybody wanting to suffer when faced with this situation.

Yet, simply put, in the UK it is against the law to assist somebody to die, whatever the circumstances. If you were to provide the links that enabled this man to go to Switzerland in order to end his life then you would be in serious trouble. Not only would you be liable to prosecution, you would also face being referred to the GMC.

Yet there is much you can do while staying in the confines of the law.

Within the time limits of a routine consultation, it would be impossible to discuss this issue fully, so it would make sense to arrange an extended appointment either at the surgery or at his home. You need to establish how his family feel about his proposals, which may prove to be a key factor in influencing the outcome.

Once all of this is done, and if the gentleman is still set on ending his life in Switzerland, who are you to stand in his way?

THE MEDICO-LEGAL VIEW

Marika Davies, medico-legal adviser at the MPS

It is important to consider your patient's request for information on euthanasia in another country within the context of the law as it stands in the UK.

The question of assisted dying has been hotly debated in recent months.

You may be familiar with the BMA's revised policy on assisted dying, which now reflects a neutral stance, and the fact that the House of Lords recently discussed this issue and that a Bill on assisted dying may be introduced in the near future.

Euthanasia is the deliberate ending of the life of a person. It is not lawful to kill another person, even if that person wants to die.

A deliberate act with the intention of ending a person's life could lead to a criminal prosecution for murder.

Under the Suicide Act 1961, it is a crime to 'aid, abet, counsel or procure' the suicide of another person.

Assisting your patient to commit suicide is a statutory offence.

Ultimately, your role in helping your patient to achieve his aim of a peaceful death is to ensure that he receives a good standard of palliative care.

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